A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?
Hypertension
Unequal pupils
Confusion
Tympany upon chest percussion
The Correct Answer is C
A. Hypertension is not typically associated with pneumonia, especially in older adults. Pneumonia can lead to hypotension or sepsis, but not usually hypertension.
B. Unequal pupils are not a typical finding associated with pneumonia. This could suggest a neurological issue or a possible eye problem, not a respiratory infection.
C. Confusion is a common sign of pneumonia in older adults, especially in the elderly, who may present with altered mental status due to hypoxia, infection, or dehydration. Delirium or confusion is a common manifestation of pneumonia in this population.
D. Tympany on chest percussion suggests air in the abdominal cavity, not in the lungs, and is not typically associated with pneumonia. Pneumonia is more likely to present with dullness upon percussion due to consolidation in the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.
Correct Answer is A
Explanation
A. Shake the MDI prior to administration: This is the correct action. Shaking the MDI ensures that the medication is evenly mixed with the propellant, which is essential for delivering the correct dose. If the inhaler is not shaken, the medication may not be properly dispensed.
B. Ask the client to inhale the medication quickly for 1 second: This is incorrect. The client should inhale slowly and deeply to ensure the medication reaches the lower airways. A quick inhalation may not allow the medication to be delivered effectively, reducing its therapeutic effect.
C. Wash the MDI canister in warm water after each use: This is incorrect. The MDI canister itself should not be washed as it may damage the device. Only the mouthpiece should be cleaned according to the manufacturer's instructions. Overwashing the device can cause malfunctions.
D. Ask the client to hold their breath for 2 seconds after inhalation: This is too short. The client should hold their breath for about 10 seconds to allow the medication to fully reach the lungs and be absorbed. A brief hold, such as 2 seconds, may not be enough to maximize the medication's effectiveness.
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